Insurance is supposed to give people a sense of safety from harm or threat. If there’s a car accident, someone will fix the car. If a fire wrecks my home, there is money to replace it. Yet the health insurance industry – with its varied “benefits” – has spent decades creating new insecurities. What’s left? That a real safety net exists only for the very, very few. Researchers measure the costs of this insecurity through lack of “access to care.” Yet the real costs – mentally, socially, and spiritually – are not counted – by bean counters or politicians. Instead they’re felt by by you and me.

How They Do It

As befits an industry which attains almost a fifth of the national economy, health insurers are ingenious. Here is just a very small sample of some of their innumerable and innovative tricks:

PreAuthorization: You need an expensive drug to treat your rheumatoid arthritis. You check out all the Medicare Part D insurers and find one who assures you – on the Bible – they will cover the medication. You buy their insurance.

But when the time comes the medication is refused.

Except you had the “guarantee” in writing.

If the insurer agrees to see the document – generally people accept the word of salesmen which is even more worthless – they are told to check the fine print. Their contract allows for “substitution” at the behest of the insurer, or disappearance of the medication from their formulary due to “market conditions” – or any reason they might care to make up.

You can get new insurance a year from now – if you’re still on the planet. In the meantime, you get your physician to fight for preauthorizion.

She will then talk on the phone to a representative who will move you to another representative who will put you on to a third, and so forth. My personal record so far is nine representatives, of whom five asked for the same information they could read on their screens – “just to check.”

After such ordeals medical personnel become wary of spending an hour on the phone to receive a fax they should have been given immediately. That fax will then ask for chart information over the last twenty or more years of treatment – demanding exact dates and results of the different medications you’ve had. At seven years many medical records are pulped – if you can get them sent from the now retired docs who filled them out. Impossible demands then lead to frequent “deauthorization.”

Variations of the preauthorization gambit include: agreeing to preauthorize, then not paying for months or years or forever; making health practitioner office staff spend hours to months resending “requested materials;” setting up arbitrary numerical allowances (‘you are allowed only one pill for day of this medication.’) There are many other ways to make the preauthorization fail.

Corruption breeds cynicism. People learn not to fight, because they will lose or spend so much time in frustrating battles that they think of little else in life. Many a parent with a sick child has quit their job to “work” full time at fighting insurance companies. Physicians learn to “go after the money,” targeting treatments and diagnostic tests that are readily paid for, not wasting time with “unpaid” actions like instructing patients or simpler, cheaper treatments that otherwise “eat into” physician work hours.

The Stall – You experience good fortune. You get preauthorized. Your treatment is considered within “standard clinical guidelines.”

They just won’t pay for it. One patient first required proof” of her retirement from her school job. None of the pieces of paper she sent were considered “satisfactory.” She kept on sending more, and never heard more for months – until she was turned down.

Her bills mounted up and up.

The Switcheroo – you think you have a practitioner lined up for your rare tumor, only to discover that they and their institution are no longer on your “provider list.”

A much more common arrangement is performed by pharmacy “benefit” companies. Often these benefits include changing generic drugs among manufacturers – without notifying you or your physicians.

When you find that the “orange pill” has become the “white pill” and then the “red pill” you are happily told that the “active ingredient” is the same.

This is technically true. However, the binding and delivery agents are different. Absorption changes. You discover this fact when your blood pressure skyrockets or you suddenly feel nauseous or your mood nosedives. The insurer blandly notes the medication is “the same.” You are told just as in TV advertisements to “ask your doctor” to change it. However when she’s on call this weekend she’s livid to discover that a standard medication has been changed repeatedly without her knowledge.

Breeding Fear

Fear of illness scares people – sometimes to death. So does fear of lack of effective insurance.

The health costs of this mess are indeed catastrophic. People spend their entire waking lives arguing with their insurance companies – often when they are dying. Believers that “the market” will fix things should consider negotiating immediately after their kid has had a car wreck, or their newly diagnosed cancer’s chemotherapy costs $60,000 per cycle – and the insurer demands a few months of paperwork before preauthorization.

The system is so broken that even truly rich people – the top .1% – tell me they need to “keep on working” to pay for the potentially staggering and unknown health care costs of the future.

What does this do to patients awaiting emergency treatments? To their families’ mental health? To the psychotherapist who must spend 40 minutes on the phone to “authorize” a 45 minute session? To the collective health of the nation?

The subject is not well studied. The health insurers – and the government – don’t readily pay for such research.

For now people continue to channel their effort into individual actions. How else do you explain that chief of the company that perpetrated the greatest (discovered) Medicare fraud in history was recently re-elected governor of Florida?

The simple explanation is fraud pays – economically and politically. A hundred million dollars buys effective political campaigns.

But fraud and fear of destitution does not buy health – economic, social, or psychological – for the people spending their time on the phone, fighting for preauthorization, for “benefits” they can no longer believe in.

People keep asking me the same questions: how can you behead children? Why do ISIS members burn a pilot alive, film the murder and triumphantly distribute it globally? If there is an answer to those questions some of it lies in ideology – the study of ideas and systems of belief. Researching ideas, much as you study photons, rocks or emotions, can help you understand the underpinnings of your own thoughts and beliefs – and that of everyone else – especially the belief that you don’t possess an ideology.

Lots of people think that way. Years ago when I was teaching at a medical branch of the University of Texas, a student came to me after a lecture. He announced in a lovely west Texas twang, “you have a real accent.” I did have a particular accent, a fractured Eastern variety filled with strangely differing pronunciations of “Mary” and “merry,” but so did he. The student smiled at my foolishness: “I don’t have an accent.”

Those who share an ideology often feel the same. They can’t understand how others can see the world differently – for what they know is so obvious.

The Power of Ideology

In a time where economists win Nobel Prizes like physicists, and “rational economic man” is given credence as a paradigm of intelligent behavior, it is sometimes hard to see the immense power of ideology. We too quickly forget the totalitarian fueled wars of the twentieth century.

Stalin was a thug, an extortionist, a train and bank robber, a practiced killer who convinced well over a hundred million people that the ideologies he penned – and Stalin wrote a lot – compelled belief like that of a deity. During the 1920s and 1930s Russians literally killed themselves to labor for the state, creating an industrial colossus out of war-torn rubble. People starved yet worked endless hours, while millions of them were simultaneously murdered.

Their crimes? Most were not only unknown to their perpetrators, but had never been considered by them. They had been literally “unthinkable.” Yet these “evil” individuals were then asked not only to confess to their non-existent crimes, but to make themselves believe their own thoughts caused them to commit those e crimes. Many acquiesced to completely rewriting history – during show trials – and in their own minds.

Generally examples of ideology trumping reality are not as stark. But consider the belief, powerful in some potent political circles, in the “hoax” of global climate change. In 2004 Naomi Oreskes, a historian of science at Harvard, was writing a book on climate change. As described in the New York Times, she decided to check the scientific literature of the previous decade to see if work disagreed with the finding that climate warming over the past 50 years was due to increased greenhouse gases. She checked over a thousand papers. None disagreed. Not one.

Publishing her results in Science, one of the most prestigious of research journals, she started receiving hate mail. She quickly discovered that many of those who “disbelieved” in greenhouse gas based climate change were not climatologists. Instead, they were weapons and rocket scientists. Presumably nuclear power, which they supported, would appear more popular as a solution to global climate change.

So why did they refuse to believe all the data? Oreskes concluded it violated their belief in free, unfettered markets. If greenhouse gases were causing climate change, then some kind of government regulation – like a carbon tax – would be needed to stop it. That violated their idea that “totally” free markets were the underpinnings of democracy. So believing that climate change is real and advancing – as climatologists do – was to these scientists equivalent to violating “freedom,” “democracy” and “the American way.” Such beliefs needed to be “debunked” – in spite of the facts.

Why We All Can’t Get Together and Agree

People are often stumped by human fractiousness. Why do people argue so much? Can’t they just sit down and rationally come to a sensible compromise?

No. Because their fundamental ideologies are often different – and deeply unexamined.

In much of today’s political debate, whether about health care, global warming, or the genocide of peoples, the communicants are not operating within the same or even similar belief systems. They think their ideals and thoughts are so basic, so bedrock, that its just “impossible” for others to think differently.

Except that they do. So in the Middle East soldiers refight the battle of Karbela – which took place in 680 – and giddily wipe out children and infants. Doctors who see guns killing more Americans than car accidents feel gun registration and potential regulation is a public health issue akin to vaccination and sanitation. To their minds it would be easy to save tens of thousands of lives – particularly the growing number of gun suicides. Many millions of gun owners see exactly the same picture as having nothing to do with health – but everything to do with freedom, democracy, and basic human rights.

It’s not easy to get people to acknowledge their basic beliefs – especially when they think they’re automatically correct. But until those beliefs are examined – and acknowledged – many of the most important debates will take only take place by people talking past each other.

Because they’re not talking about the same things – and they don’t realize it. Such is the power of ideology – to disappear itself in plain sight, and shape our views of the world – whatever the facts.Rest, sleep, Sarasota Sleep Doctor, well-being, regeneration,healthy without health insurance, longevity, body clocks, insomnia, sleep disorders, the rest doctor, matthew edlund, the power of rest, the body clock, psychology today, huffington post, redbook, longboat key news

Is getting cancer mostly a matter of luck? That was the spin on a a recent study by Vogelstein and his team at Johns Hopkins. Media stories led to furious counterarguments among scientists – before running back into media self-commentary. Yet the real lessons of this interesting, assumption filled paper have been widely neglected. They include 1. Take out lifestyle events like smoking, drinking and obesity – and elements of genetics – and most of the reasons for cancer risk remain unknown. 2. Cancer may well be a disease of incorrect regeneration. 3. The randomness of much cancer incidence argues for blanket treatment coverage. If we treat everyone experiencing “random” accidents, why not cancer?

So What Did the Study Really Show?

The study by well known cancer researchers looked mainly at statistical variability – how much a disease appears in a population based on factors you know – and the ones you don’t.

The authors focused on stem cells – the relatively undifferentiated stuff used to make tissues new. As most of your body gets replaced quickly, stem cells matter.

The plan was to look at estimates of stem cell regeneration rates – how fast different tissues are remade – to understand cancer rates. Data on breast and prostate cancer were left out. The authors felt the data on their stem cell regeneration rates were too lousy to use. Other researchers thought their guesses about other tissues not great, either.

But when looking at how fast stem cells regenerate – how quickly tissues remake themselves – the correlation with cancer rate variability came out a high .81. This was interpreted by the authors to mean using the statistical rule of multiplying correlation by itself – that approximately two thirds (.81 times .81) of the rates of tumor variability were “explained” by how fast stem cells remake tissues.

In other words – the more completely new cells you make, the more errors. The more errors – the more tumors. Tissues that are replaced in days – like gut lining cells – have a lot more tumors found that tissues that replace themselves slowly, over years.

This is like saying that a group of drivers traveling a hundred thousand miles is more likely to experience accidents than if they drove five thousand miles. It does not tell you about cause – like bad weather or faulty brakes. It only says statistical variability goes up – in a fairly predictable way – if you have to remake stuff more often.

What Does This Mean For Cancer Biology?

That despite over 40 years since the beginning of Nixon’s “War on Cancer,” we really have not majorly changed cancers rates, nor, for most tumors, ultimate survival statistics. We certainly know a lot more about cancers – including that the tissue types we’ve used to diagnose disease do not include the dozens of different tumors glimpsed on the molecular level. We also know tumors rapidly mutate – effectively becoming different animals. That partly explains why most chemotherapies work for limited periods – the tumors change before our eyes, giving them a hydra headed capacity to block effective treatment.

One remedy that has been suggested – including by the Johns Hopkins authors – to look for earlier tumor detection. For now, that’s a pipe dream. As H. Gilbert Welch pointed out in “Overdiagnosis,” a lot of present day cancer screening is not supported by evidence. If for every prostate cancer identified and cured via the prostate serum antigen test – the PSA – you end up treating 30 to 100 people unnecessarily, you have not accomplished your goal.

With the growth of health monitoring equipment and “nanomedicine” expect to see widespread, sometimes uncontrolled screening. Beware. The American IT foray into medical care- with hundreds of different incompatible electronic health record systems that have nurses and doctors treat charts instead of people, and security systems sufficiently robust to allow your most intimate secrets to be hacked by an intelligent teenager – represents a small foretaste of what may come. The process can be done right – and generally is done far better in rationalized, nationalized, European health systems. But “personalized medicine” will only be ready for prime time when it improves the health of populations – not just corporate ledgers.

Lastly, we have to face two curious facts: that cancer is much related to how accurately our tissues regenerate themselves – and that many of these errors are indeed random.

Though not all. The biggest impacts on human health are still those of lifestyle, not medicine. Lifestyle adds far more to lifespans than medical care does. To prevent cancer you don’t send people first for screening tests – you get them to walk, eat whole foods, drink less and smoke not at all.

And if cancer, the most feared and soon to be greatest overall killer of humanity, is mainly random in who it destroys – whether it’s a two year old with acute lymphocytic leukemia or an accounting professor with brain cancer – how can we withhold treatment from people on the basis of poverty or employer? If someone is in a car crash we treat them. Why treat tumors differently?

Ultimately, the data on cancer tells us what we’ve known all along – that we’re all in the same boat. It’s incumbent on us to help everybody else in the boat, too – if only to save ourselves.